Planning in Health Organizations Discussion.

For the exclusive use of A. Williams, 2022. W16190 PLEASANT BLUFFS: LAUNCHING A HOME-BASED HOSPITAL PROGRAM Laura Erskine wrote this case solely to provide material for class discussion. The author does not intend to illustrate either effective or ineffective handling of a managerial situation. The author may have disguised certain names and other identifying information to protect confidentiality. This publication may not be transmitted, photocopied, digitized or otherwise reproduced in any form or by any means without the permission of the copyright holder. Reproduction of this material is not covered under authorization by any reproduction rights organization. To order copies or request permission to reproduce materials, contact Ivey Publishing, Ivey Business School, Western University, London, Ontario, Canada, N6G 0N1; (t) 519.661.3208; (e) cases@ivey.ca; www.iveycases.com. Copyright © 2016, Richard Ivey School of Business Foundation Version: 2016-04-07 In the late 1990s, home-based hospital care started to be introduced in the United States and worldwide. This initiative seemed to lower costs, improve quality, and positively impact patient satisfaction.1 In early March 2014, Graff Salot, the director of Performance Improvement (PI) at Pleasant Bluffs Health System (Pleasant Bluffs), was asked by the chief executive officer to develop a proposal, including a business case and an outline of a pilot program, for a Pleasant Bluffs version of home-based hospital care. Salot was expected to present his proposal at the monthly session of the health system leadership team on April 30, 2014. PLEASANT BLUFFS HEALTH SYSTEM Pleasant Bluffs Medical Center was created in the late 1950s, as a result of the merger between two longstanding local hospitals. With the addition of a helipad in the mid-1980s, the hospital became a Level 1 Trauma Center,2 a facility able to provide care for every type of injury or illness. By the early 1990s, the medical center had become Pleasant Bluffs Health System, which included a medical care foundation, a physician-hospital organization, and a medical care center. Pleasant Bluffs was frequently recognized in national rankings of hospitals. The non-profit medical center had more than 400 licensed beds and provided outpatient care, acute and subacute patient care, biomedical research, and graduate and undergraduate medical education. It operated both as an academic medical center and community hospital, engaged in population health and prevention, and had a large portion of patients over age 85. Pleasant Bluffs employed over 5,000 individuals (including some physicians who were employed by the foundation) and worked with an additional 1,000 private physicians. Hospitalists employed by Pleasant Bluffs also staffed the emergency department (ED) at Community Medical Center (Community), which was less than eight kilometres away. This document is authorized for use only by Abigale Williams in HSA 4140 Spring 2022 taught by SCOTT FEYEREISEN, Florida Atlantic University from Jan 2022 to Jul 2022. For the exclusive use of A. Williams, 2022. Page 2 9B16M058 PERFORMANCE IMPROVEMENT The PI department at Pleasant Bluffs managed projects and cross-functional process improvement teams. The teams used Lean Six Sigma, Plan Do Check Act, and Innovation/Design Thinking to improve clinical quality. These methodologies used cross-functional teams to improve performance by reducing waste (e.g., defects, overproduction, delays, inventory, etc.). Individuals in the department also participated in the annual quality strategic planning process and any regulatory or accreditation surveys that included reviews of PI processes. The PI team reported up to the chief executive officer, through the senior vice president for Service Line Operations. GRAFF SALOT Salot joined the PI department in 2008, and became its director in September of 2013.

Before joining Pleasant Bluffs, he had worked at two different hospitals in Washington, DC. Salot had a Master of Public Health and a Bachelor of Business Administration from universities on America’s East Coast. He was a Lean Six Sigma Master Black Belt3 and spoke three languages. He had been closely tracking home-based hospital care projects at other hospitals — the most prominent of which were Johns Hopkins (Hopkins) and Presbyterian Healthcare Services (PHS). Hopkins registered its program as Hospital at Home© under copyright. HOME-BASED HOSPITAL CARE PROJECTS Driven by the Patient Protection and Affordable Care Act, commonly known as the Affordable Care Act (ACA),4 signed into law in March of 2010, payers (insurance companies and other third-party payers) were restructuring their contracts with hospitals to lower costs and 30-day readmission rates.

5 The Centers for Medicare & Medicaid Services (CMS) also announced the introduction of financial penalties for hospitals with higher-than-predicted readmission rates for patients with heart attacks, congestive heart failure, and pneumonia.6 In addition, there was pressure to keep patients, especially older ones, out of hospitals because of their vulnerabilities to hospital-borne infections and other complications.7 One way of addressing the external pressure was the Hospital at Home© model developed by researchers at the Johns Hopkins Schools of Medicine and Public Health in 2001.8 For those individuals sick enough to require medical care but not sick enough to require hospitalization, nursing and physician treatment was provided in the patient’s home. Some examples of the medical services provided included administering and monitoring medications, home safety assessments, assistance to caregivers, diagnostic tests (including X-rays, ultrasound, and electrocardiograms), wound treatment, blood draws, oxygen therapy, pain management, and lifestyle improvements.9 In a 2002 study that took place in three different locations, 141 Hopkins patients over the age of 65 with one of four conditions (community-acquired pneumonia, exacerbation of chronic heart failure, exacerbation of chronic obstructive pulmonary disease, or cellulitis) were offered the option of receiving medical care in their homes rather than being admitted to the hospital.10 In two of the three piloted locations, 69 per cent opted to receive care at home; in the third location, 29 per cent opted for home care. Patients treated at home had a shorter length of stay (3.2 versus 4.9 days) and fewer complications. The mean cost of care was also lower for Hospital at Home© patients (US$5,08111 versus $7,480).

Some time after the 2002 study was done, several other hospitals tried variations of the program, including PHS in Albuquerque, New Mexico in 2011.12 The results at PHS mirrored those from Hopkins (see Exhibit 1). This document is authorized for use only by Abigale Williams in HSA 4140 Spring 2022 taught by SCOTT FEYEREISEN, Florida Atlantic University from Jan 2022 to Jul 2022. For the exclusive use of A. Williams, 2022. Page 3 9B16M058 PLEASANT BLUFFS: HOME-BASED CARE Salot and his team thought that a home-based care program could work for members of the Accountable Care Organization (ACO) populations at Pleasant Bluffs. ACOs were groups of healthcare providers that shared financial and medical responsibility for providing coordinated care to patients.

CMS used performance on 33 quality measures in four domains (patient/caregiver experience, care coordination/patient safety, preventative health, and at-risk population) to determine whether an ACO could share in the savings generated.13 Pleasant Bluffs had ACO contracts with Medicare, Aetna, and Anthem. For this population, it was in the hospital’s financial interest to reduce spending, mainly through shorter stays and fewer unnecessary tests. The PI team had been monitoring the ACO patient population at Pleasant Bluffs for three months by examining Pleasant Bluffs hospital admissions data each morning. Analysis of admitted patients that entered the hospital through the ED showed that, though sick, some patients had conditions that did not necessarily require admission. Based on the team’s internal assessments, approximately 20 per cent (600 individuals) of the admitted ACO patients were sick but could possibly have been treated at home. To find out how many of the patients actually fit the criteria to receive care at home, Pleasant Bluffs purchased the Hopkins algorithm for $20,000.

Medicare used a coding system that incorporated all costs required to treat a specific condition. These were known as Medicare Severity Diagnosis-Related Groups (MS-DRGs). The algorithm used these DRG codes (see Exhibits 2 and 3), expected length of care, and comorbidities (additional disorders or diseases co-occurring with the primary disease) to determine whether a patient was suitable for the Hospital at Home© program. The doctor was then able to use this information to make decisions about the plan of treatment. Based on the Hopkins algorithm, 7 per cent of Pleasant Bluffs’ readmitted patients could have been successfully treated at home. While PI was gathering data about Medicare ACO patients that might be able to receive care at home, a Pleasant Bluffs senior vice-president (SVP) shared with Salot a story of his father (not a Pleasant Bluffs patient) who was discharged with home nursing.

He felt this was a great idea, and although not actually involved in the PI data-gathering project, he began to champion the idea and advocate internally for a pilot program. With encouragement from the SVP and other leaders, Salot and the PI team were tasked with developing a business case and creating a pilot program for a Pleasant Bluffs version of home-based hospital care for the ACO patient population. COSTS The PI team knew that in order to launch a pilot program, Pleasant Bluffs would require a relationship with a home health company, access to durable medical equipment (walkers, wheelchairs, bed rails, hospital beds, etc.), an agreement with a laboratory that could process samples collected by nurses, and a pharmacy that would agree to deliver medications to patients’ homes. Based on estimates of leasing medical equipment and contracting for nursing, laboratory, and pharmacy services, the PI team estimated homebased care would average between $750 and $1,250 per patient per day.

Salot also wondered about program management. Should the home-based hospital program have a dedicated administrative or clinical staff member? LOCATION OF THE PILOT PROGRAM The PI team had two choices with respect to the location of the pilot program: Pleasant Bluffs or Community. This document is authorized for use only by Abigale Williams in HSA 4140 Spring 2022 taught by SCOTT FEYEREISEN, Florida Atlantic University from Jan 2022 to Jul 2022. For the exclusive use of A. Williams, 2022. Page 4 9B16M058 Pleasant Bluffs Hospital Pleasant Bluffs was a non-profit academic medical center that provided comprehensive inpatient and outpatient services, as well as 24-hour emergency care. Compared to Community, Pleasant Bluffs had a higher inpatient cost of care — slightly higher than the regional average ($2,200 per patient per day) and about 50 per cent higher than the cost at Community. The ED was operating beyond capacity almost all the time and admitted an average of 15 per cent of the approximately 225 patients that arrived each day. As a result, long wait times at Pleasant Bluffs led to frequent complaints from visitors. Patients arriving at the ED were covered by a variety of insurance plans and came from a wide geographic region of more than 500 square kilometres with more than 20 million residents.

These people varied in demographic characteristics and may have been patients of any of the over 1,000 physicians (many with a preference for admitting patients) who had privileges at Pleasant Bluffs. Since Pleasant Bluffs was also a teaching hospital, medical residents played a role in providing clinical care in that ED. Approximately 55 per cent of the Pleasant Bluffs patients were Medicare-eligible, and half of them were above age 85. Community Medical Center Community was a physician-owned, acute-care, community hospital with fewer than 250 beds. The hospital provided comprehensive inpatient and outpatient services and 24-hour emergency care. Compared to Pleasant Bluffs, Community had a lower inpatient cost of care, below the regional average. Although treating patients with serious chronic conditions, Community did not experience the severity or complexity of comorbidities that Pleasant Bluffs did. This population was more ethnically homogeneous than the Pleasant Bluffs population. Twenty salaried Pleasant Bluffs hospitalists provided care in the ED at Community and admitted an average of 10 per cent of the approximately 100 patients that arrived each day. Most hospitalists were board-certified in internal medicine and were dedicated inpatient physicians.14 Approximately 45 per cent of the ED patients were Medicare-eligible and only one-third were above age 85. Planning in Health Organizations Discussion.

Compared to Pleasant Bluffs, the ED had a much lower volume of the kind of patients that might be eligible for the pilot program. Community had ACO contracts with Cigna and Medicare. About 90 per cent of the patients came from an eight-kilometre radius of the hospital and, on average, Community patients tended to be less sick than Pleasant Bluffs patients. The PI team also wondered whether any changes had to be made to the existing ED intake processes (see Exhibit 4) and how to incorporate a choice of home-based care. A visit to the ED cost the hospital approximately $500 in professional services for each patient. At Pleasant Bluffs, that cost usually doubled with the addition of ancillary services and tests. At Community, ancillary tests and services added approximately $200. Although both EDs struggled with overcrowding, this was especially pronounced for Pleasant Bluffs, where the elapsed time from a patient’s arrival in the ED to being admitted could exceed 12 hours (compared to a national average of 279 minutes or 4.65 hours).15 Much of the delay was due to waiting for clinicians, tests, and available beds (both in the ED and on the inpatient floors). Not only did the backlog have an impact on centers within the hospital, it also impacted urgent care clinics. Patients could become sicker while waiting in the ED. Planning in Health Organizations Discussion.

ELIGIBLE PATIENT POPULATION Salot and the PI team also needed to make recommendations about which patients would be considered suitable for the program. Age was an important factor, but there were other considerations. Should the team This document is authorized for use only by Abigale Williams in HSA 4140 Spring 2022 taught by SCOTT FEYEREISEN, Florida Atlantic University from Jan 2022 to Jul 2022. For the exclusive use of A. Williams, 2022. Page 5 9B16M058 choose the entire population or reduce that number based on the age characteristics of the two hospitals or the ACO populations? Should the team add geographic restrictions? Which medical conditions should be eligible? Based on the published research, and the purchased algorithm, the team knew that Hopkins restricted participation based on condition.16 Only patients with one of four conditions (community-acquired pneumonia, exacerbation of chronic heart failure, exacerbation of chronic obstructive pulmonary disease, or cellulitis) were eligible to participate in the program. In contrast, PHS selected nine diagnostic groups (based on suitability and frequency of admissions).17 Like Hopkins, PHS included community-acquired pneumonia, exacerbation of chronic heart failure, exacerbation of chronic obstructive pulmonary disease, and cellulitis. Planning in Health Organizations Discussion.

PHS also added patients with deep vein thrombosis, pulmonary embolism, complicated urinary tract infection or urosepsis, nausea and vomiting, and dehydration. If Pleasant Bluffs were to select the same conditions and protocols as Hopkins, it would be required to license the name Hospital at Home© for a recurring fee. In addition, it was worried about a small pilot volume if it included only the four Hopkins conditions. The key criteria were twofold: a population for whom home-based care would be effective and reduce readmission possibilities following the treatment, and a population for whom clinician concerns about liability would be lower. Although Hopkins was not specific about any geographic restrictions, PHS restricted the program to those patients who lived within 40 kilometres of the hospital. In 2012, the population density18 near PHS in Albuquerque was approximately 2,200 people per square kilometres, and the area around Hopkins had a population density of approximately 12,000 people per square kilometre. By comparison, the 2012 population density for the area around both Pleasant Bluffs and Community was approximately 8,800 people per square kilometre.

LENGTH OF THE PILOT Although Salot was not seeking publication opportunities as a result of the pilot program, a large enough sample would be needed to demonstrate the effectiveness of the home-based hospital program. The length of the pilot would ultimately be decided by the number of patients who accepted the offer to participate. Salot and his team felt that a minimum of 30 patients would need to participate in order for the team to assess whether home-based hospital care could save the organization money. Encouraging participation was critical. Many patients believed that being hospitalized would be safer and would eliminate some concerns related to patients being left on their own. It would be up to doctors to educate patients about the efficacy of a home-based hospital program. What should the program be called? What methods could the team use to educate doctors and other clinicians? What methods could clinicians use to educate eligible patients? CONCLUSION Salot knew that he was facing some significant challenges. He had to prepare a comprehensive home-based hospital care pilot program for Pleasant Bluffs that included specifications about location, medical condition coverage, patient eligibility, critical data to collect, appropriate means of data collection, and the length of the study. Planning in Health Organizations Discussion.

He also knew his proposal would have to include projected costs and potential benefits, and the program had to make financial sense. This document is authorized for use only by Abigale Williams in HSA 4140 Spring 2022 taught by SCOTT FEYEREISEN, Florida Atlantic University from Jan 2022 to Jul 2022. For the exclusive use of A. Williams, 2022. Page 6 9B16M058 EXHIBIT 1: SELECTED RESULTS FOR HOME-BASED HOSPITAL CARE TRIALS Number of medical conditions covered Four:  Communityacquired pneumonia  Exacerbation of chronic heart failure  Exacerbation of chronic obstructive pulmonary disease  Cellulitis Age Geographic restriction Accepted offer of home-based care Length of study Number of patients Average length of stay (days): home versus inpatient Cost: home versus inpatient care Patient satisfaction (measured by Press Ganey): home versus inpatient > 65 years None 60% 11 months 144 3.2 versus 4.9 Presbyterian Healthcare Services Nine:  Community-acquired pneumonia  Exacerbation of chronic heart failure  Exacerbation of chronic obstructive pulmonary disease  Cellulitis  Deep venous thrombosis  Pulmonary embolism Planning in Health Organizations Discussion.

 Complicated urinary tract infection or urosepsis  Nausea and vomiting  Dehydration > 65 years Within 40 kilometres 93% 43 months 582 3.3 versus 4.5 32 % lower at home Not published 19 % lower at home 90.7 versus 83.9 Johns Hopkins Sources: Bruce Leff, Lynda Burton, Scott L. Mader, Bruce Naughton, Jeffrey Burl, Sharon K. Inouye, William B. Greenough III, Susan Guido, Christopher Langston, Kevin D. Frick, Donald Steinwachs, and John R. Burton, “Hospital at Home: Feasibility and Outcomes of a Program to Provide Hospital Level Care at Home for Acutely Ill Older Patients,” Annals of Internal Medicine 143, no. 11 (2005): 798–808; Lesley Cryer, Scott B. Shannon, Melanie Van Amsterdam, and Bruce Leff, “Costs for ‘Hospital at Home’ Patients Were 19 Percent Lower, With Equal or Better Outcomes Compared to Similar Inpatients,” Health Affairs 31, no. 6 (2012): 1237–1243; “Press Ganey,” accessed March 7, 2016, www.pressganey.com. This document is authorized for use only by Abigale Williams in HSA 4140 Spring 2022 taught by SCOTT FEYEREISEN, Florida Atlantic University from Jan 2022 to Jul 2022. For the exclusive use of A. Williams, 2022. Page 7 9B16M058 EXHIBIT 2: MEDICARE SEVERITY DIAGNOSIS RELATED GROUP (MS-DRG) REIMBURSEMENT AND LENGTH OF STAY MS-DRG (without complications) 176 192 195 293 295 392 603 641 690 Condition Pulmonary embolism Exacerbation of chronic obstructive pulmonary disease (COPD) Community-acquired pneumonia Exacerbation of chronic heart failure Deep venous thrombosis Nausea and vomiting Cellulitis Dehydration Complicated urinary tract infection or urosepsis 2013 Mean Length of Stay (days) 4.2 2013 Average Medicare Payments (US$) $5,854.88 3.3 $3,754.48 3.4 $3,684.10 3.1 $3,749.59 3.6 3.5 4.2 3.4 $4,750.61 $4,078.81 $4,679.63 $3,916.06 3.8 $4,395.46 Source: “FY 2013 IRF PPS Notice Data Files,” Centers for Medicare & Medicaid Services, accessed March 4, 2016, www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/InpatientRehabFacPPS/Data-Files.html; “Inpatient Charge Data FY 2013,” Centers for Medicare & Medicaid Services, accessed March 4, 2016, www.cms.gov/Research-Statistics-Data-andSystems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/Inpatient2013.html.

This document is authorized for use only by Abigale Williams in HSA 4140 Spring 2022 taught by SCOTT FEYEREISEN, Florida Atlantic University from Jan 2022 to Jul 2022. For the exclusive use of A. Williams, 2022. Page 8 9B16M058 EXHIBIT 3: CONDITION DESCRIPTIONS Cellulitis (MS-DRG: 603; ICD-10: L03): A bacterial infection of the skin that is characterized by redness, pain, swelling, fever, and chills. Treatment involves the use of antibiotics.

Chronic Obstructive Pulmonary Disease (MS-DRG: 192; ICD-10: J44): Also known as COPD, a persistent narrowing or obstruction of the airways, leading to chronic bronchitis or emphysema. COPD is most often associated with cigarette smoking and is characterized by shortness of breath and coughing. Patients may require medication, rehabilitation, and/or supplemental oxygen. Dehydration (MS-DRG: 641; ICD-10: E86): Results from a lack of sufficient water in the body and associated imbalances of blood solutes (electrolytes) such as sodium and potassium. Dehydration is characterized by thirst, headache, absence of perspiration, confusion, and decreased urine output. Treatment consists of fluid replacement therapy, both oral and intravenous, depending on severity. Deep Vein Thrombosis (MS-DRG: 295; ICD-10: I80.2): Also known as DVT, the formation of blood clots in the deep veins, and is most often seen in the lower extremities. Multiple risk factors are associated with DVTs, including immobility, age, and injury. Complications associated with DVTs include emboli (a pulmonary embolism is life threatening), chronic venous insufficiency, and ischemia. Anticoagulants, compression, monitoring, and thrombolytic medications may be employed during treatment. Congestive Heart Failure (MS-DRG: 293; ICD-10: I50): Planning in Health Organizations Discussion.

Results from inadequate blood flow from the heart. Congestive heart failure has multiple causes and associated risk factors. Patients are often asymptomatic in the initial stages but may later present with shortness of breath and fatigue. Depending on the underlying cause, congestive heart failure may be treated with medications, lifestyle changes, and surgical interventions. Nausea and Vomiting (MS-DRG: 392; ICD-10: R11): Comprises both the symptom of vomiting and the unpleasant feeling that may precede it. Nausea and vomiting result from a plethora of causes and may be accompanied by an associated illness, unwillingness to eat, and dehydration. Treatment for nausea and vomiting is dependent upon the determined cause, and may or may not require intervention. Pneumonia (MS-DRG: 195; ICD-10: J12): An infection of the lower respiratory tract. Infections leading to pneumonia are acquired from a variety of sources and associated illnesses. Symptoms of pneumonia include productive cough, fever, chills, and shortness of breath. Antimicrobial medications and supportive therapies are employed in the treatment of pneumonia, depending on the cause. Pulmonary Embolism (MS-DRG: 176; ICD-10: I26): Planning in Health Organizations Discussion.

A blockage in the arteries of the heart or lungs that often results from a blood clot or other matter in the cardiovascular system. Symptoms of acute pulmonary embolism include chest pain, shortness of breath, and fainting. Anticoagulants, thrombolytics, and surgery may be employed in treatment. Urinary Tract Infection/Urosepsis (MS-DRG: 690; ICD-10: N39): Upper and lower infections of the urinary system caused by multiple microorganisms, treated with antimicrobial medications and supportive therapy. Source: 3M Health Information System, Medicare Severity Diagnosis Related Group (MS-DRGs): Definitions Manual (Washington, DC: 3M Health Information System, 2008); World Health Organization, ICD-10: International Statistical Classification of Diseases and Related Health Problems, 10th revision (Geneva: World Health Organization, 2007); A. Damian Dhar, “Cellulitis,” Merck Manual: Consumer Version, accessed March 7, 2016, www.merckmanuals.com/home/skin-disorders/bacterial-skin-infections/cellulitis; Robert A. Wise, “Chronic Obstructive Pulmonary Disease (Chronic Bronchitis, Emphysema),” Merck Manual: Consumer Version, accessed March 7, 2016, www.merckmanuals.com/home/lung-and-airway-disorders/chronic-obstructive-pulmonary-disease(copd)/chronic-obstructive-pulmonary-disease-(chronic-bronchitis,-emphysema); James L. Lewis III, “Dehydration,” Merck Manual: Consumer Version, accessed March 7, 2016, www.merckmanuals.com/home/hormonal-and-metabolic-disorders/waterbalance/dehydration; James D. Douketis, “Deep Vein Thrombosis (DVT),” Merck Manual: Consumer Version, accessed March 7, 2016, www.merckmanuals.com/home/heart-and-blood-vessel-disorders/venous-disorders/deep-vein-thrombosis-(dvt); J. Malcolm O. Arnold, “Heart Failure (Congestive Heart Failure),” Merck Manual: Consumer Version, accessed March 7, 2016, www.merckmanuals.com/home/heart-and-blood-vessel-disorders/heart-failure/heart-failure#v718861; Norton J. Greenburger, “Nausea and Vomiting in Adults,” Merck Manual: Consumer Version, accessed March 7, 2016, www.merckmanuals.com/home/digestive-disorders/symptoms-of-digestive-disorders/nausea-and-vomiting-in-adults; Sanjay Senthi, “Overview of Pneumonia,” Merck Manual: Consumer Version, accessed March 7, 2016, www.merckmanuals.com/home/lung-andairway-disorders/pneumonia/overview-of-pneumonia; Victor F. Tapson, “Pulmonary Embolism (PE),” Merck Manual: Consumer Version, accessed March 7, 2016, www.merckmanuals.com/home/lung-and-airway-disorders/pulmonary-embolism/pulmonaryembolism; Talha H. Imam, “Overview of Urinary Tract Infections,” Merck Manual: Consumer Version, accessed April 7, 2016, www.merckmanuals.com/home/kidney-and-urinary-tract-disorders/urinary-tract-infections-(uti)/overview-of-urinary-tract-infections. This document is authorized for use only by Abigale Williams in HSA 4140 Spring 2022 taught by SCOTT FEYEREISEN, Florida Atlantic University from Jan 2022 to Jul 2022. Planning in Health Organizations Discussion.

For the exclusive use of A. Williams, 2022. Page 9 9B16M058 EXHIBIT 4: ER INTAKE PROCESS FOR PLEASANT BLUFFS AND COMMUNITY HOSPITALS (AVERAGE TIME ELAPSED) Elapsed Time (hh:mm) 0:00 0:05 Pleasant Bluffs Patient enters the ER Triage Nurse checks symptoms and vital signs Elapsed Time (hh:mm) 0:00 0:05 Community Patient enters the ER Triage Nurse checks symptoms and vital signs 0:20 Admissions process 0:20 Admissions process 0:35 3:30 Patient waits Patient escorted to exam room ER Nurse takes patient history and conducts physical exam and begins ordering tests to rule out diagnoses Patient waits ER Doctor completes history and physical exam; examines suggested tests and confirms (might add tests); creates ER treatment plan; completes minor procedures (e.g., sutures, medication) Patient has blood tests and imaging to confirm diagnosis 0:35 2:30 Patient waits Patient escorted to exam room ER Nurse takes patient history and conducts physical exam

Treatment plan is executed by ER Nurse and Pharmacist ER Doctor reassess patient to determine whether patient is stable and responding to treatment plan If unable to care for themselves, patient is scheduled for admission; if able to care for themselves, patient is discharged Patient is transferred to an inpatient bed 4:00 3:35 4:00 4:30 5:00 6:00 8:00 9:00 11:30 2:35 2:45 3:15 Patient waits ER Doctor completes history and physical exam; might order tests; creates ER treatment plan; completes minor procedures (e.g., sutures, medication) 3:00 If ordered, patient has blood tests and imaging to confirm diagnosis Treatment plan is executed by ER Nurse and Pharmacist ER Doctor reassess patient to determine whether patient is stable and responding to treatment plan If unable to care for themselves, patient is scheduled for admission; if able to care for themselves, patient is discharged Patient is transferred to an inpatient bed 5:30 6:00 7:30 Source: Discussions between the case author and decision makers at Pleasant Bluffs. This document is authorized for use only by Abigale Williams in HSA 4140 Spring 2022 taught by SCOTT FEYEREISEN, Florida Atlantic University from Jan 2022 to Jul 2022. Planning in Health Organizations Discussion.

For the exclusive use of A. Williams, 2022. Page 10 9B16M058 ENDNOTES 1 Lesley Cryer, Scott B. Shannon, Melanie Van Amsterdam, Bruce Leff, “Costs for ‘Hospital at Home’ Patients Were 19 Percent Lower, With Equal or Better Outcomes Compared to Similar Inpatients,” Health Affairs 31, no. 6 (2012): 1237–1243; Sheila Eckenrode, Anila Bakullari, Mark L. Metersky, Yun Wang, Michelle M. Pandolfi, Deron Galusha, Lisa Jaser, and Noel Eldridge, “The Association Between Age, Sex, and Hospital-Acquired Infection Rates: Results From the 2009–2011 National Medicare Patient Safety Monitoring System,” Infection Control & Hospital Epidemiology 35, no. S3 (2014): S3–S9; Susan L. Hughes, Frances M. Weaver, Anita Giobbie-Hurder, Larry Manheim, William Henderson, Joseph D. Kubal, Alec Ulasevich, Joan Cummings, and Department of Veterans Affairs Cooperative Study Group on Home-Based Primary Care, “Effectiveness of TeamManaged Home-Based Primary Care:

A Randomized Multicenter Trial.” Jama 284, no. 22 (2000): 2877–2885; Sasha Shepperd and Steve Iliffe, “Hospital at Home Versus In-Patient Hospital Care,” Cochrane Database System, Rev. 3 (2005). 2 “Trauma Levels Explained,” American Trauma Society, accessed March 4, 2016, www.amtrauma.org/?page=TraumaLevels. 3 “Black Belt Certification,” International Association for Six Sigma Certification, accessed March 4, 2016, www.iassc.org/sixsigma-certification/black-belt-certification. 4 Patient Protection and Affordable Care Act, 42 U.S.C. § 18001 et seq. (2010). 5 The 30-day unplanned readmission measures are estimates of unplanned readmission, due to any cause, to any acute care hospital within 30 days of discharge from a hospitalization: “30-Day Unplanned Readmission and Death Measures,” Medicare.gov, accessed March 4, 2016, https://www.medicare.gov/hospitalcompare/Data/30-day-measures.html. 6 “Readmission Reduction Program (HRRP),” Centers for Medicare & Medicaid Services, accessed March 4, 2016, https://www.cms.gov/medicare/medicare-fee-for-service-payment/acuteinpatientpps/readmissions-reduction-program.html. Planning in Health Organizations Discussion.

7 Eckenrode, et al, op. cit. 8 “About Hospital at Home,” Hospital at Home, accessed March 4, 2016, www.hospitalathome.org/about-us/overview.php. 9 “How It Works,” Hospital at Home, accessed March 4, 2016, www.hospitalathome.org/about-us/how-it-works.php. 10 Bruce Leff, Lynda Burton, Scott L. Mader, Bruce Naughton, Jeffrey Burl, Sharon K. Inouye, William B. Greenough III, Susan Guido, Christopher Langston, Kevin D. Frick, Donald Steinwachs, and John R. Burton, “Hospital at Home: Feasibility and Outcomes of a Program to Provide Hospital Level Care at Home for Acutely Ill Older Patients,” Annals of Internal Medicine 143, no. 11 (2005): 798–808 11 All currency amounts are in US$ unless otherwise specified. 12 Cryer, Shannon, Van Amsterdam, and Leff, op. Planning in Health Organizations Discussion.

cit. 13 “Quality Measures and Performance Standards,” Centers for Medicare & Medicaid Services, accessed March 4, 2016, https://www.cms.gov/Medicare/Medicare-Fee-for-Service Payment/sharedsavingsprogram/Quality_Measures_Standards.html 14 “General Information,” Society of Hospital Medicine, accessed March 4, 2016, www.hospitalmedicine.org/Web/About_SHM/ General%20Information/About_SHM/Industry/General_Information_About_SHM.aspx?hkey=f7e1acde-fe83-4852-bf5588fe2fc7b967 Planning in Health Organizations Discussion.